Technical details for a robot-assisted hand-sewn esophago-gastric anastomosis during minimally invasive Ivor Lewis esophagectomy.

BACKGROUND: Minimally invasive Ivor Lewis esophagectomy (MIILE) provides better outcomes than open techniques, particularly in terms of post-operative recovery and pulmonary complications. However, in addition to requiring advanced technical skills, thoracoscopic access makes it hard to perform esophagogastric anastomosis safely, and the reported rates of anastomotic leak vary from 5 to 16%. Several minimally invasive esophago-gastric anastomotic techniques have been described, but to date strong evidence to support one technique over the others is still lacking. We herein report the technical details and preliminary results of a new robot-assisted hand-sewn esophago-gastric anastomosis technique. METHODS: From January 2018 to December 2020, 12 cases of laparoscopic/thoracoscopic Ivor Lewis esophagectomy with robot-assisted hand-sewn esophago-gastric anastomosis were performed. The gastric conduit was prepared and tailored taking care of vascularization with a complete resection of the gastric fundus. The anastomosis consisted of a robot-assisted, hand-sewn four layers of absorbable monofilament running barbed suture (V-lock). The posterior outer layer incorporated the gastric and esophageal staple lines. RESULTS: The post-operative course was uneventful in nine cases. Two patients developed chyloperitoneum, one patient a Sars-Cov-2 infection, and one patient a late anastomotic stricture. In all cases, there were no anastomotic leaks or delayed gastric conduit emptying. The median post-operative stay was 13 days (min 7, max 37 days); the longest in-hospital stay was recorded in patients who developed chyloperitoneum. CONCLUSION: Despite the small series, we believe that our technique looks to be promising, safe, and reproducible. Some key points may be useful to guarantee a low complications rate after MIILE, particularly regarding anastomotic leaks and delayed emptying: the resection of the gastric fundus, the use of robot assistance, the incorporation of the staple lines in the posterior aspect of the anastomosis, and the use of barbed suture. Further cases are needed to validate the preliminary, but very encouraging, results.

Molecular detection of TP53, Ki-Ras and p16INK4A promoter methylation in plasma of patients with colorectal cancer and its association with prognosis. Results of a 3-year GOIM (Gruppo Oncologico dell'Italia Meridionale) prospective study.

BACKGROUND: Despite the improvement in detection and surgical therapy in the last years, the outcome of patients affected by colorectal carcinoma (CRC) remains limited by metastatic relapse. The aim of this study was to investigate the presence of free tumor DNA in the plasma of CRC patients in order to understand its possible prognostic role. PATIENTS AND METHODS: Ki-Ras, TP53 mutations and p16(INK4A) methylation status were prospectively evaluated in tumor tissues and plasma of 66 CRC patients. RESULTS: In 50 of the 66 primitive tumor cases (76%) at least one significant alteration was identified in Ki-Ras and/or TP53 and/or p16(INK4A) genes. Eighteen of the 50 patients presented the same alteration both in the plasma and in the tumor tissue. At univariate analysis, Ki-Ras mutations proved to be significantly related to quicker relapse (P <0.01), whereas only a trend towards statistical significance (P = 0.083) was observed for the TP53 mutations CONCLUSIONS: Detection of Ki-Ras and TP53 mutation in plasma should be significantly related to disease recurrence. These data suggest that patients with a high risk of recurrence can be identified by means of the analysis of tumor-derived plasma DNA with the use of fairly non-invasive techniques.

Significance of P16INK4A hypermethylation gene in primary head/neck and colorectal tumors: it is a specific tissue event? Results of a 3-year GOIM (Gruppo Oncologico dell'Italia Meridionale) prospective study.

BACKGROUND: Methylation of the p16 promoter is one of the most frequent mechanisms of gene inactivation; its incidence is extremely variable according to the type of tumor involved. Our purpose was to analyze the hypermethylation of the p16 promoter in laryngeal squamous cell carcinomas (LSCC), salivary gland (SG) tumors and in colorectal cancer (CRC), to detect any possible association with the clinicopathological features and to determine the prognostic significance of the p16 gene in the tumors analyzed. PATIENTS AND METHODS: The hypermethylation of the p16 promoter was prospectively analyzed, by MSP, in a consecutive series of 64 locally advanced LSCC patients, in a consecutive series of 33 SG tumor patients and in a consecutive series of 66 sporadic CRC patients. RESULTS: Hypermethylation was observed in 9% of the LSCC cases, in all cases of SG cancer and in 21% of the CRC cases. No significant association was observed between p16 hypermethylation and clinicopathological variables in all the tissue samples analyzed. Moreover at univariate analysis p16 mutations were not independently related at disease relapse and death in LSCC and CRC. CONCLUSIONS: The results of this study suggest that the lack of p16 function could happen in advanced stage of SG tumors.

Radio-frequency thermal ablation (RFTA) of small hepatocellular carcinoma in patients with cirrhosis. Experience at a single tertiary referral center.

AIM: Radio-frequency thermal ablation (RFTA) may prolong the survival of patients with small hepatocellular carcinoma (HCC) associated with cirrhosis. The aim of this study was to evaluate efficacy and safety of RFTA. METHODS: We performed the Kaplan-Meier analysis to estimate the survival rate in 69 consecutive patients with HCC (mean age 66+/-6.5 years; 44/25 male/female; 56 Child-Pugh class A and 13 Child-Pugh class B) treated by RFTA. A single lesion was observed in 60/69 (87%), two lesions in 8/69 (11.6 %), and 3 lesions in 1/69 (1.4 %) of patients. The tumor size was = or <3 cm in 60/69 (87%). RESULTS: Twenty-two patients died during follow-up. Overall survival rates were 81%, 66%, and 46% at 1-, 2-, and 3-years, respectively. Cancer-free survival rates were 64% at 1 year, 30% at 2 years and 25% at 3 years. The 3-years rate of appearance of separate new lesions and local recurrence were 27.5% (19/69) and 26 % (18/69). CONCLUSIONS: Our study shows that patients with HCC and compensated cirrhosis may benefit from RFTA treatment, especially for tumors = or <3 cm. Nevertheless, the high rate of recurrence (both local and distant) points out the palliative role of this therapy.

DNA ploidy and S-phase fraction, but not p53 or NM23-H1 expression, predict outcome in colorectal cancer patients. Result of a 5-year prospective study.

PURPOSE: The aim of this study was to determine TP53 and NM23-H1 immunoreactivity, DNA ploidy, and S-phase fraction (SPF) in a series of 160 patients undergoing resective surgery for primary operable colorectal cancer (CRC) and to establish whether these alterations have any clinical value in predicting CRC patients' prognosis. METHODS: TP53 and NM23-H1 expressions were evaluated on paraffin-embedded tissue by immunohistochemistry and DNA-ploidy and SPF on frozen tissue by flow-cytometric analysis. RESULTS: The median follow-up time in our study group was 71 months (range 34-115 months). P53 protein expression was associated with distal tumors (P<0.05) and DNA aneuploid tumors (P<0.05) tumors. DNA-aneuploidy was associated with distal tumors (P<0.01), histological grade (G3) (P<0.05), advanced Dukes' stage (C and D) (P<0.01), lymph node metastases (P<0.01) and high SPF (>18.3%) (P<0.01). The major significant predictors for both disease relapse and death were advanced Dukes' stage, DNA-aneuploidy, and high SPF, while lymphohematic invasion was the only independent factor for relapse and non-curative resection for death. CONCLUSIONS: Our results indicate that DNA aneuploidy and high SPF are associated in CRC with a poor clinical 5-year outcome, while in contrast the prognostic role of TP53 and NM23-H1 expression is still to be clarified.

Totally implantable venous access devices implanted surgically: a retrospective study on early and late complications.

BACKGROUND: The techniques used for the implantation of totally implantable venous access devices (TIVADs) are the percutaneous approach and surgical cutdown; however, the choice is still controversial. HYPOTHESIS: The surgical cutdown approach may be beneficial to reduce the rate of complications. DESIGN: Retrospective review. SETTING: A university hospital and a tertiary referral center. PATIENTS: Patients undergoing a TIVAD implant at the First Surgical Clinic of the University of Catania in Catania, Italy, between January 1995 and December 1999, were considered for the study. All of the devices were implanted in an operating room under fluoroscopic control. The vein of choice was the cephalic vein. When the cephalic vein was not suitable for implantation, the external jugular vein or the axillary vein and its branches were used. The percutaneous approach to the subclavian vein or internal jugular vein was considered a last resort to implant a catheter. RESULTS: During the study period, 346 TIVADs were implanted in 344 patients. The procedure was performed with local anesthesia in 341 cases (98.5%), and only 2 patients (0.6%) required sedation for psychological reasons. Three patients (0.9%) had their TIVAD placed during a laparotomy. In 326 patients (94.2%), the devices were implanted in the cephalic vein. In the remaining cases, other veins were used with surgical cutdown. The mean time for the procedure was 15 minutes. Percutaneous access was never used, and no early mechanical complications were recorded. Only 6 patients (1.8%) in our study group had late complications (1 case of migration of the catheter, 2 cases of infection, and 3 cases of withdrawal occlusion). The catheter life ranged from 6 to 1487 days (mean time, 348 days). CONCLUSION: Our results confirm the safety, speed, and low cost of the open cutdown technique. This surgical procedure avoids both early and late complications that frequently occur with percutaneous access. Surgical cutdown should be considered the technique of choice to implant the TIVAD, especially in cancer patients.

A new simple laparoscopic-extracorporeal technique for the repair of a Morgagni diaphragmatic hernia.

We used a new technique to treat a right-sided Morgagni hernia in a symptomatic adult with a transverse colon that was herniated in the chest. Three trocars were required. The herniated viscera were easily reduced in the abdomen, and the diaphragmatic border that was mobilized from the liver showed the elliptical diaphragmatic defect (9 x 5 cm); however, the hernial sac was not resected. Four transversal 1-cm cutaneous incisions were made just below the costal arch. Using a Reverdin needle holder, we introduced eight ligatures under laparoscopic control through the abdominal wall and through the free diaphragmatic border. Each suture was then held by the grasper and freed from the Reverdin. After the Reverdin was extracted and reintroduced more caudally, the intraabdominal suture was placed into it and finally extracted again. Before knotting, all the sutures were pulled together to achieve perfect closure of the defect. A suction drain was placed in the hernial sac. The duration of the procedure was 12 min. The patient was discharged on the 5th postoperative day. A review of 20 other patients treated via a video-assisted approach is also included here. We found this original technique to be extremely simple, rapid, and effective. It can also be performed by surgeons who are not specially trained in intracorporeal suturing and knotting and can probably also be used for the repair of other types of diaphragmatic defects. The use of laparoscopy and magnification allows the surgeon to achieve a better point of control for simpler solutions.

Pancreas transplantation in the rat using Lee's technique: a reliable model in experimental microsurgery.

Numerous unresolved problems, both technical and immunological, in pancreas transplantation stimulate experimental studies. Dogs have been routinely used in experimental studies but today rats are more commonly used. However, pancreas transplantation in the rat presents complex technical problems and requires a good knowledge of microsurgical techniques. In 1983 Squifflet undertook an experimental study aimed at evaluating the technical aspects of pancreas transplantation in the rat and calculating the success rates using different methods. The comparison of four methods revealed to our surprise that 100% of the rats operated on using Lee's technique had complications, with a 0% survival rate. In our study we report our experience using Lee's technique which we had the opportunity of mastering directly under the supervision of Professor Lee. We performed 100 pancreas transplantations using Lee's technique and divided our study in two phases. In the first phase we performed 70 pancreas transplantations and overall survival, after 1 week, was 42 rats (60%). In the second phase on 30 rats diabetes was induced by administering 70 mg/kg of streptozotocin. These 30 diabetic rats underwent pancreas transplantation and overall survival, after 1 week, was 25 (83.3%). We believe that our successful survival rates could probably be explained by the close collaboration between Lee and our department. Moreover, we noted the importance of constant training in obtaining better results, and in our opinion Lee's technique of pancreas transplantation is a reliable experimental model which can be used to resolve problems linked to pancreas transplantation.

Radio-hyperthermia for subcutaneous metastasis of hemangiopericytoma of the mediastinum: case report.

Hemangiopericytoma is a rare type of neoplasia originating from the Zimmermann pericytes and can arise in numerous sites. As it is difficult to correlate the histologic aspect with the prognosis, it was considered advisable to take account of other factors such as age and tumoral site. Aggressive surgery followed by irradiation therapy is suggested as the most suitable management. Hyperthermia also was adopted in treating subcutaneous metastasis, but its role has yet to be fully defined.

Which kind of surgery in elderly people for colorectal cancer?

Colo-rectal cancers are of high incidence in elderly patients. Different clinical features and the peculiar behavior of the tumor may influence surgical results and should be considered in the decision making, when the surgeon has to decide whether to perform radical gut resection or less straining palliative procedures. In a retrospective study, 102 large bowel cancer patients are analyzed submitted to surgery in the period 1989-1994. Patients were divided in two age classes: Group A: above 70 years of age, 45 cases (44.2%); Group B: under 70 years of age, 57 cases (55.8%). Emergency surgery procedures were necessary in 35 patients (34.4%), 20 cases (57%) in Group A and 15 cases (43%) in Group B. Radical resections could be performed in 25 (37%) old patients, 67% of the cases underwent a curative resection. Perioperative mortality and surgical complication rates were significantly higher in Group A than in Group B. The technical and biological difficulties in performing radical curative resections, the high complication rates and the occurrence of negative results of treatments provide a reason for careful evaluation of the risk/benefit ratio in older patients, where less straining palliative therapies may sometimes offer similar results.

Extravascular migration of the catheter. A rare complication of the totally implantable venous device.

Since the first report of TIVD implantation, many authors have published immediate and post-operative complications. The Authors report the first case in which the catheter, implanted via the cephalic vein by cutdown technique, has migrated completely out of the vein. In order to avoid extravascular migration, during the surgical procedure, the catheter should be fixed at the vein with nonabsorbable sutures, taking care to avoid narrowing the catheter lumen. This case report discusses the possibility of catheter migration when a TIVD fails to function properly and considers how to avoid more disastrous effects.

[Axillofemoral bypass: a potential solution of acute ischemia of the lower limb]. / Il bypass axillofemorale: una possibile soluzione dell'ischemia acuta dell'arto inferiore.

When deobstruction by Fogarty catheter fails, the axillofemoral bypass can be considered as a therapeutic solution of the acute ischaemia of the limb. The authors discuss a case occurred in their experience and focus their attention on the therapeutic potentiality of this kind of revascularization. As a matter of fact it is important to consider that the operation should not only eliminate the acute ischaemia, but also correct the atherosclerotic lesions that led to it. Therefore, if deobstruction by Fogarty catheter does not restore a good inflow, in high risk patients with acute arterial thrombosis of the limb, there is a well indication for extra-anatomic revascularization.

[Role of somatostatin and parenteral nutrition in the treatment of acute pancreatitis. Personal experience]. / Ruolo della somatostatina e della nutrizione parenterale nel trattamento della pancreatite acuta. Esperienze personali.

The aim of the study was to evaluate and control the therapeutic validity of Somatostatin administration and the clinical benefits of parenteral nutrition during acute pancreatitis. We selected 31 patients with 1st and 2nd degree pancreatitis according to Ranson's classification. Diagnosis was based on clinical and humoral data and confirmed by echography and CT examinations. The most common etiological cause was biliary++ lithiasis (74.2%). All the patients in the study were split into two groups and received conventional treatment. The therapeutic schedule administered to group 1 included somatostatin (250 micrograms/h for 72-96 h), while group 2 received total parenteral nutrition with 2,000-2,500 Kal/day trough a central vein. The data obtained from our study demonstrated that both somatostatin and parenteral nutrition are valid tools during the acute phase of the disease. It must be pointed out that the former significantly influences the clinical course and allows a precise control of the painful symptomatology, the objective picture and the curve of the main hematochemical parameters. Parenteral nutrition betters the anabolic response of the organism during the acute phase and carries out an indirect antienzymatic response, so favouring a quicker recovery than observed in the group treated with somatostatin.

[Mixed-type pancreatoblastoma. Report of a clinical case]. / Pancreatoblastoma di tipo misto. Presentazione di un caso clinico.

Pancreatoblastoma is a very rare tumor of the pancreas, affecting children in the first decade of life. Ultrasound and CT scan may be useful but pre-operative diagnosis is often quite difficult. High level of seric alpha-fetoprotein could be suggestive of pancreatoblastoma. The definitive diagnosis is however made by histologists when an organoid structure, well encapsulated, consisting of acinar cells with zymogen-like granules and squamoid corpuscle is demonstrated, sometimes associated with mesenchymal tissue (mixed-type pancreatoblastoma). Immunohistochemical studies may help in differentiating pancreatoblastoma from papillary cystic tumors, acinar cell carcinomas and endocrine pancreatic tumors of the pancreas. We report a case of mixed-type pancreatoblastoma in a 12-year-old female patient, located in the head of the pancreas. The treatment has been surgical, consisting of a duodeno-cephalo-pancreasectomy. Neither radiotherapy nor chemotherapy has been performed. The patient is alive, without recurrence, four months after the operation. Diagnostic, therapeutic and prognostic aspects are discussed.

[A rare association: antral neurinoma with gastric volvulus]. / Una rara associazione: il neurinoma antrale ed il volvolo gastrico.

The paper describes a very rare case of obstructing antral neurinoma with associated gastric volvulus. Pathogenetic mechanism of this association, which has never been reported in the literature, is discussed. The authors also focus their attention on the diagnostic difficulties and the choice of therapy. A hiatoplasty and a Billroth II gastrectomy were performed in the described case.

[Bilateral adrenal pheochromocytoma. A clinical case and review of the literature]. / Feocromocitoma surrenalico bilaterale. Caso clinico e revisione della letteratura.

The authors present a case of bilateral adrenal pheochromocytoma that occurred at their observation and surgically treated with a bilateral adrenalectomy. The authors review the literature in order to discuss the diagnostic and therapeutic option to treat these cases. They stress the importance of preoperative abdominal TC an MIBG scintigraphy and the importance of pre and intraoperative assessment to exclude extra adrenal localization of pheochromocytoma.

[Oxiracetam treatment of exogenous post-concussion syndrome. Statistical evaluation of results]. / Trattamento con oxiracetam della sindrome post-commotiva esogena. Valutazione statistica dei risultati.

The aim of the study was to evaluate the clinical use of a GABOB by-product in the treatment of exogenous post-concussion syndrome. Thirty-six patients affected by this syndrome were included in the study and divided into two groups. Patients in the first group were treated with the drug, while patients in the second group were not treated. Variations in the average time taken for symptoms to disappear in both groups showed a statistically significant difference in favour of the drug-treated group of patients. Following an analysis of the results it was possible to affirm that the drug had a statistically significant effect in patients affected by medium-severe symptomatology.

Does cholecystectomy always resolve biliary disease?

OBJECTIVE: To evaluate long-term effects of cholecystectomy on typical gallstone symptoms and associated digestive syndrome. DESIGN: Clinical prospective study on selected patients. SETTING: First Surgical Clinic--Catania University. SUBJECTS: 143 gallstone patients, divided in highly symptomatic Group 1 (79) and mild symptomatic Group 2 (64), who underwent cholecystectomy during period 1991/92. MAIN OUTCOME MEASURES: 125/143 patients compiled a set questionnaire to detect any subjective postoperative disorders and to evaluate whether they were similar to preoperative symptoms or were new ones. RESULTS: 125/143 patients completed the 12-month follow-up programme, which revealed a 30% (38/125) with postcholecystectomy symptoms and 13.4% (17) with a postcholecystectomy syndrome. Moreover, 10% (13) of the patients reported the same digestive symptoms as before treatment. Statistical analysis confirmed that cholecystectomy was efficacious in curing gallstone related symptoms and digestive disorders in both Groups with a general improvement in clinical picture (p > 0.01). No significant statistical difference in the incidence of postcholecystectomy dyspeptic symptoms was found between the 2 Groups. CONCLUSION: Cholecystectomy is often efficacious in curing both typical gallstone related symptoms and digestive syndrome. Cholecystectomy patterns of failure in curing digestive disorders is unpredictable preoperatively on the basis of clinical features of the disease.

[External oblique muscle-cutaneous flap use of the in the reconstruction of large chest wall defects after mastectomy]. / Utilizzazione del lembo muscolo-cutaneo di obliquo esterno nella ricostruzione della parete toracica dopo mastectomia allargata.

The use of an external oblique muscle-cutaneous flap in the reconstruction of large chest wall defects after mastectomy is described. The flap is drown as a V-Y advancement-rotation flap, laterally based, on the ipsilateral abdominal wall. The flap extends from the posterior axillary line to the linea alba, vascular supply is provided by the musculo-cutaneous perforating arteries of the intercostal vessels. Mobilization starts medially including the anterior rectus sheath, décollement continues between the external and the internal oblique muscles as far as the posterior axillary line. The abdominal wall, after flap mobilization, is reinforced by the plication of the internal oblique sheath. The flap was used in 13 patients with major anterior chest-wall defects after mastectomy. In one patient a marginal skin necrosis of about 2 cm was observed. The flap described differs from other external oblique flaps already described in several technical innovations that allow to obtain better functional and esthetic results.

[Migration of the catheter of a totally implantable venous system. A rare mechanical complication]. / Migrazione del catetere di un sistema totalmente impiantabile. Una rara complicanza meccanica.

Catheter migration, represents a rare, mechanical complication following the use of totally implantable venous devices. A case, in which the catheter was inserted into the right internal jugular vein by percutaneous route, without radiological control, is described. Following the chemotherapy infusion drugs, the patient developed a catheter displacement and subcutaneous extravasation. Etiological hypotheses and modalities of prevention are discussed.